Registration Application and Pledge for Smoking Cessation Outpatient Treatment Cost Subsidy Program

禁煙外来治療費助成金交付事業登録申請書兼確約書

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This is a registration application and pledge form for receiving treatment under Meguro Ward's smoking cessation outpatient treatment cost subsidy program. Applicants must provide required details and pledge their consent to resident registry inquiries and cooperation with related surveys.

What	目黒区禁煙外来治療費助成金交付事業の登録申請および同意・協力の確約
Who	目黒区で禁煙外来治療費助成金交付事業による治療を受けようとする人
When	記載なし
Where	目黒区長宛て（目黒区）
How	登録申請書兼確約書に住所、電話番号、氏名、生年月日等を記入し、住民基本台帳情報の調査への同意およびアンケート調査への協力を確約して提出する
Deadline	記載なし
Contact	記載なし

Open the original PDF ↗ 1 pages

Source page: https://www.city.meguro.tokyo.jp/kenkousuishin/kenkoufukushi/kenkou/kinenjosei_2.html
Checked 2026-09-12. This page restates the PDF in a fixed structure; nothing is added or removed. Where the PDF does not say, the field reads "not stated". The original Japanese PDF is authoritative — confirm dates and conditions there.